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House Calls: Demystifying Ben Roethlisberger’s Injury

It was landing on his elbow as he got sacked that caused Roethlisberger’s injury. (J.D. Cavrich/www.altoonamirror.com)

The media storm hit Pittsburgh in full force Tuesday morning, just hours after Steelers QB Ben Roethlisberger left the Monday Night Football game at Heinz Field against the Kansas City Chiefs after taking a sack. Roethlisberger was evaluated in the locker room and subsequently sent to a local hospital that night for an MRI to further evaluate his injury. His agent, Ryan Tollner, mysteriously called the injury “non-traditional” and said it was ”unique” and “not something the training staff typically sees.”

Twitter buzzed for hours as sports reporters speculated whether the franchise QB had sustained a shoulder separation or merely a sprain to the shoulder on his all-important throwing arm. The following day, head coach Mike Tomlin described the injury as a sternoclavicular (SC) joint sprain. Most analysts were anticipating an acromioclavicular (AC) joint injury, which involves the attachment of the clavicle, or collarbone, to the scapula, or shoulder blade. The SC joint is the connection between the clavicle and the sternum (breastbone), a less common injury. Reporters, bloggers, and fans hit up google to estimate when Roethlisberger might return — a critical question with the Steelers playing their division rival Ravens twice in the next 3 weeks. If you want to become an expert on disorders (atraumatic and traumatic) of the SC joint, check out Chapter 33 of “Disorders of the Shoulder: Diagnosis and Treatment”. Or just check out their treatment algorithm for traumatic injuries.

I turned to my local sports medicine orthopaedic surgery experts to get their input. The general consensus was that the injury would cause pain but no instability to the shoulder and therefore wouldn’t affect his throwing strength or accuracy. They estimated Roethlisberger’s return to be 2-3 weeks, which might allow for Ben to face the Ravens in the second match. Things didn’t seem so bleak.

Another day, another diagnosis. Roethlisberger arrived at the South Side facility early Wednesday morning for the usual team meetings, sporting a black sling to support his right arm. Around that time, Ed Bouchette, who covers the Steelers for the Pittsburgh Post-Gazette, tweeted the following:

Ed Bouchette ‏@EdBouchette

#Steelers Ben Roethlisberger has a rare rib injury that could kill him by pressing against his aorta. Too big risk. Has to wait until heals

Bouchette followed it up later in the day with an article further detailing the potentially lethal injury. This announcement is exactly the type of drama that Coach Tomlin prefers to avoid, and Big Ben certainly didn’t seem to be on death’s door when speaking with reporters. Allow me to clarify some of the hyperbole…

Roethlisberger was told by his physicians that this injury is so rare that the last known case was seen in 1998 in a rugby player. This is, in fact, the only case report in the medical literature and can be found in the British Journal of Sports Medicine from 1999. It should be noted that the rugby player also sustained a fracture to the posterior sternum, so it was actually a more extensive injury. That player took 12 weeks off, until an Xray showed that the fracture had healed completely. Keep in mind that ruby players wear no padding or protection.

Why was this injury potentially fatal? According to Ben (per his physicians), he had a posterior displacement of the first rib, which attaches to the sternum but curves up behind the clavicle. If the rib is pushed back far enough, it can cause serious injury to major blood vessels or the lung, resulting in significant bleeding or a collapsed lung. That is why the QB was taken to the hospital so expediently. This is different than the injury sustained by St. Louis Rams wide receiver Danny Amendola a few weeks ago. Amendola had a posterior dislocation of the clavicle at the SC joint, also an unusual injury. That, too, could have caused injury to a major blood vessels behind the clavicle, and I’m still surprised that his doctor’s supposedly reduced it in the locker room under sedation rather than in a hospital. It sounds like if Roethlisberger had a dislocation of the clavicle, it was displaced anteriorly instead. You can see the difference here:

The million-dollar (or $102 million question) is how long it will take Roethlisberger to return to playing. Initial treatment for this injury is simply immobilizing the arm and wrapping the chest to prevent recurrent dislocation. Surgical repair is rarely indicated; it’s usually not necessary and has a significant complication rate. If he were dealing with only the SC joint sprain, he would likely be out for a week or two. In 2010, warrior QB Brett Favre’s 297-game consecutive start streak was interrupted by the same injury, but he was able to return under center after missing only 1 game.

The rib dislocation is the complicating factor. Given that it is such a rare injury, Roethlisberger’s physicians can only take a wait-and-see approach. Clearly, they will not allow the QB to return to contact before the rib injury is healed or he will be at risk for a recurrent dislocation and the complications that can arise. In the absence of a fracture, however, it may be difficult to gauge the healing. My guess — and it is, of course, just that — is that his doctor’s will monitor the healing based on his pain level.

A conservative estimate would place Roethlisberger on the bench for 6 weeks, which is nearly the rest of the regular season. Then again, where Big Ben is concerned, all bets are off. He has proven his toughness (making his label of “drama queen” laughable) again and again, playing through foot fractures, a broken thumb on his right hand, a high ankle sprain, and even the broken nose delivered by Ravens DT Haloti Ngata last season. The trainers snapped his nose back in place, packed it, and sent him back out to win the game.

The bottom line is that it’s way too soon to predict when Roethlisberger will resume his QB duties, but Coach Tomlin said it best today during a media session, as reported on twitter by an NFL Network reporter:

Aditi Kinkhabwala ‏@AKinkhabwala

Mike Tomlin asked if he expects Ben back this season. Snorts. Then says: “Next question.”

Melanie Friedlander, MD is a board-certified general surgeon. You can send her medical questions about your favorite (or not-so-favorite) NFL players and follow her at www.twitter.com/girlsurgeon.

The rib dislocation is the complicating factor. Given that it is such a rare injury, Roethlisberger’s physicians can only take a wait-and-see approach. Clearly, they will not allow the QB to return to contact before the rib injury is healed or he will be at risk for a recurrent dislocation and the complications that can arise. In the absence of a fracture, however, it may be difficult to gauge the healing. My guess — and it is, of course, just that — is that his doctor’s will monitor the healing based on his pain level.A conservative estimate would place Roethlisberger on the bench for 6 weeks, ...which is nearly the rest of the regular season.

Melanie Friedlander, MD is a board-certified general surgeon. You can send her medical questions about your favorite (or not-so-favorite) NFL players and follow her at www.twitter.com/girlsurgeon.

The key part of this post is the one in green - the injury is: a) not a fracture so that its healing can't be followed like a fractured bone can, and b) so rare that there is only one other reported case in the literature.

So how does a doc "sign off" on the stability of this? Seems like shy of applying gametime forces on the ligament/cartilage and seeing how much it gives, it would be very hard to clear Ben to take hits again. And even that isn't predictive about how the joint will behave the next time those forces are applied.

Important to realize this post was written by a general surgeon, not an orthopedic surgeon. As she clearly stated, she checked with an orthopedic surgeon for the details about the injury. The part in red just sounds like her conjecture, which isn't something to bet much on, IMO.

Great post, Hawaiian, thanks for sharing. First time I've heard anything reasonably reliable about the posterior displacement of the rib.

I've got to think the Steelers would rather err on the side of caution in this one. Who would want to be the one to green-light Ben's return, only to have him suffer a puncture of a major blood vessel or a lung because he wasn't truly healed? They may well decide to shelve him until next season.

Seems like the information is evolving as we go along. This injury is very rare as stated, so not many docs are experts on this particular injury. The best information I could find on the injury agreed with the 6 week assessment. But, this warned it may take longer because the athlete can not train while in pain from the dislocation.

I've got to think the Steelers would rather err on the side of caution in this one. Who would want to be the one to green-light Ben's return, only to have him suffer a puncture of a major blood vessel or a lung because he wasn't truly healed? They may well decide to shelve him until next season.

And I think that is what will happen unless the Steelers make the playoffs...which IMO is remote without Ben.